Management infant born with mother Chickenpox

Literature review Literature review Over 85 % of women of childbearing age in industrialised countries are immune to varicella zoster virus (VZV) Varicella pneumonia complicates up to 10 % of cases of VZV in pregnancy Perinatal varicella (chickenpox) carries a 20 to 30 % risk of transmission to the neonate

Route of transmission Infection with chickenpox may occur through airborne / respiratory droplet and direct contact with vesicle fluid Transmission based precautions (negative pressure room, immune staff in attendance, N95 mask) should be used when caring for a woman / baby with chickenpox In herpes zoster (shingles), transmission of infection usually requires contact with vesicle fluid; however, there is also evidence of respiratory spread

Incubation period 10 to 21 days (may be up to 35 days in contacts given Varicella Zoster Immune Globulin, Period of infectivity 48 hours before the onset of rash until crusting of all lesions (usually day 6 of rash) Varicella (and herpes zoster) vesicles contain large numbers of virus particles. Ensure transmission based precautions (negative pressure room, immune staff in attendance, N95 mask) are used and all dressing materials treated as medical waste

Maternal VZV infection can cause three major manifestations: 1. Congenital defects secondary to intrauterine VZV infection 2. Neonatal chickenpox 3. Zoster (shingles) in infants

fetal varicella syndrome Studies of maternal varicella in the first 20 weeks suggest a 2 – 2.8 % risk of fetal varicella syndrome. Subsequent abnormalities may include: Skin scarring Eye defects Limb hypoplasia Prematurity and low birthweight Cortical atrophy, mental retardation Poor sphincter control Early death

Neonatal chickenpox Disease begins in the neonate within the first 10 days of life If an infant's mother develops varicella from 5 days before to 2 days after delivery,the infection is usually disseminated and fulminant , approximately 1/3 die, diffuse pneumonia, severe hepatitis and meningoencephalitis are the most common clinical manifestations. skin vesicles DDx from neonatal HSV infection

Indication for VZIG Immunocompromised children without history of chickenpox Susceptible, pregnant women Newborn infant whose mother had onset of chickenpox within the 5 days before delivery or within 2 days after delivery Hospitalized premature infant (>28 wk GA) whose mother has no history of chickenpox or seronegativity Hospitalized premature infant (<28 wk GA), regardless of maternal history

Isolation: airbone and contact precaution 1.Patient with varicella: minimum of 5 days after the onset of the rash and as long as the rash remains vesicular 2.Exposed, susceptible to varicella: 8-21 days after the onset of rash in index patient (28 days if received VZIG) 3.Immunocompromised patient with zoster (localized or disseminated) 4.Normal patient with disseminated zoster ( localized, normal pt needs only standard precaution)

Summery of Management Maternal Time Risk Treatment Isolation - Varicella 1) 0-20 wk GA Congential syndrome Acyclovir, if life threatening to mother No   2) 13-36 wk GA Zoster in infancy same as #1 3) 5 days before to 2 days after delivery Severe neonatal chickenpox VZIG to newborn, Acyclivir is symptomatic Yes 4) around delivery except #3 mild neonatal chickenpox closed observation - Zoster 0-36 wk GA none